Annie Zhu, BHSc; Chuck Resnick; Jeremy Rezmovitz, MSc, MD, CCFP
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=G19-0019.
Author/Illustrator Information: Annie Zhu is a medical student at the University of Toronto. She is interested in sequential art and exploring narratives in medicine. Her other illustrations and comics can be found at cazezhu.carbonmade.com. Chuck Resnick is currently the Vice President of Operations and Marketing for a service-based Canadian company headquartered in Toronto. This story was written by him and inspired by his experiences. Dr. Jeremy Rezmovitz is a family physician working in Toronto. He is Lead for CPD and Innovation and Assistant Professor in the Department of Family and Community Medicine at the University of Toronto. His passion is education scholarship and facilitating tools of engagement to improve patient care.
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Icahn School of Medicine at Mount Sinai
October 21, 2019
Frying Pan to Fire
Imagine how you would have felt if you had successfully transitioned to ranitidine and then started seeing the news about carcinogens in Zantac!😧
Dept of Surgery, Nykoping Hospital and Karolinska Institute, Stockholm
October 23, 2019
Cure is a better option for this one
Who says vomiting and belching is a concern after fundoplication? On the contrary, vomiting is not even possible, and belching becomes much less pronounced. In fact, this may lead to bloating, which most often gradually diminishes within the first postop year. There are alternative methods to Nissen, with a lower risk of persistent bloating.
John W. Eikelboom, Paul Moayyedi
Population Health Research Institute, Hamilton Health Sciences and McMaster University
October 29, 2019
PPIs for Happily Ever After: Lesson Six
To the Editor:Zhu and colleagues elegant illustration of the challenges of proton pump inhibitor de-prescribing lists five lessons for patients and health care providers. We were particularly impressed by our protagonist’s initiative to do some more research to understand the possible risks of proton pump inhibitors, and his perceptive insights regarding the differences between association, as reported in many observational studies, and causation, which is much more difficult to prove and ideally requires randomization. This leads us to suggest one additional lesson. It is not only the media that chooses their words in a way that suits their intended outcome(s); the same can be said for authors of the papers reporting the benefits and harms therapeutic interventions, as well as journal editors who publish their papers. We recently reported the results of an international, randomized, blinded trial examining the effects of pantoprazole compared with placebo on upper gastrointestinal tract complications as well as on safety outcomes of interest (1, 2). This was not only one of the largest such trials ever performed (n=17,598) but also had one of the longest follow-ups (median 3.01 years), and is the only trial so far to report long term safety. Believing that our finding of no significant harm of pantoprazole compared with placebo for any outcome other than enteric infection would be of great general medical interest, we attempted to publish our data in the same high profile journals that had reported that proton pump inhibitors cause renal, hepatic, cardiac and neurological diseases, but were rejected. We finally published our results in the leading specialty journal, where they are clearly accessible but less likely to be widely read that if they had been published in a general medical journal. Perhaps this explains why our protagonist did not reference our paper; had he seen it, he would likely have gained further reassurance about his decision to resume treatment with a proton pump inhibitor. Hence, we propose lesson 6: Similar to the popular media, medical journals choose their words (in the form of papers) in a way that suits their intended outcomes. 1. Moayyedi P, Eikelboom JW, Bosch J, Connolly SJ, Dyal L, Shestakovska O, Leong D, Anand SS, Störk S, Branch KRH, Bhatt DL, Verhamme PB, O'Donnell M, Maggioni AP, Lonn EM, Piegas LS, Ertl G, Keltai M, Cook Bruns N, Muehlhofer E, Dagenais GR, Kim JH, Hori M, Steg PG, Hart RG, Diaz R, Alings M, Widimsky P, Avezum A, Probstfield J, Zhu J, Liang Y, Lopez-Jaramillo P, Kakkar A, Parkhomenko AN, Ryden L, Pogosova N, Dans A, Lanas F, Commerford PJ, Torp-Pedersen C, Guzik T, Vinereanu D, Tonkin AM, Lewis BS, Felix C, Yusoff K, Metsarinne K, Fox KAA, Yusuf S; COMPASS Investigators. Gastroenterology 2019;157:403-4122. Moayyedi P, Eikelboom JW, Bosch J, Connolly SJ, Dyal L, Shestakovska O, Leong D, Anand SS, Störk S, Branch KRH, Bhatt DL, Verhamme PB, O'Donnell M, Maggioni AP, Lonn EM, Piegas LS, Ertl G, Keltai M, Bruns NC, Muehlhofer E, Dagenais GR, Kim JH, Hori M, Steg PG, Hart RG, Diaz R, Alings M, Widimsky P, Avezum A, Probstfield J, Zhu J, Liang Y, Lopez-Jaramillo P, Kakkar AK, Parkhomenko AN, Ryden L, Pogosova N, Dans AL, Lanas F, Commerford PJ, Torp-Pedersen C, Guzik TJ, Vinereanu D, Tonkin AM, Lewis BS, Felix C, Yusoff K, Metsarinne KP, Fox KAA, Yusuf S; COMPASS Investigators. Gastroenterology 2019;157:682-691.
University of Toronto
October 28, 2019
Replying to comments
Reply to David Sachar:Thank you for your comment. Yes, the story from the patient narrative occurred over two years ago; and we had been following the guidelines at that time. The Zantac warnings didn't come out until recently but we had already created the submission before then. The most important thing we're hoping to illustrate in this comic is the patient narrative of the process of deprescribing!Reply to Bengt Novik.Thank you for your comment. Although we're not experts in these surgical procedures, this comic is meant to highlight a patient's experience and what they were told when they discussed these procedures with their GI physician & the result of their own readings and decisions. Thus, at that time they decided to not go through with it.I'm sure for many people, surgery is a cure to their problem and that these procedures were very effective for them. However, we are hoping to highlight in this comic the focus of patient decision-making and at the time, these were the reasons why the patient in the narrative decided to forego surgery.
Replying to comment
To John W. Eikelboom, Paul Moayyedi:Thank you very much for your comment. We fully agree with your point.
Zhu A, Resnick C, Rezmovitz J. Annals Graphic Medicine - PPIs for Happily Ever After?. Ann Intern Med. 2019;171:W53–W61. [Epub ahead of print 22 October 2019]. doi: https://doi.org/10.7326/G19-0019
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Published: Ann Intern Med. 2019;171(9):W53-W61.
Published at www.annals.org on 22 October 2019
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